Dialysis: Chronic Disease in Developing Nations

by Jenna Frawley

While chronic kidney disease does not receive as much media attention as cancer or heart disease, it is a comparably common and deadly problem. Most cases of chronic kidney disease will eventually lead to renal failure. After renal failure, there are only two options for survival: a kidney transplant or frequent dialysis treatments. The leading cause of chronic kidney disease is Type II Diabetes Mellitus, which is generally associated with more affluent countries due to its connection with obesity and hypertension. However, recent research suggests that the number of patients with Type II Diabetes is expected to double in developing nations within next two decades.

Developing nations face a great burden with this trend, as treatments for end-stage renal disease are very expensive and have low availability. Many countries struggle with an inequality between government-run hospitals that serve the general public and private hospitals that only the top of the upper class can afford. Governments also vary in what treatments they can afford and are willing to cover. Furthermore, lack of registries and comprehensive studies make it difficult to estimate the exact number of afflicted people. These are all issues that Dr. John Ball, a Chicago nephrologist and founder of the Bridge of Life Charity, knows well.

Q: So how did you become involved with this issue?

A: I was making rounds at a charity hospital in Bolivia in 1991. I stopped in at the renal ward, as that is my specialty, and there were about 40 patients there all with varying degrees of renal failure. Over the course of my trip, I learned that there was not a single dialysis unit in the city of Santa Cruz and so by the end of it every one of these patients had died because they lacked the treatment they needed.

Even twenty years ago, one would be hard-pressed to find a hospital in the United States without at least one hemodialysis unit at the ready. Hemodialysis is the system in which a person’s blood vessels are hooked up via needles to a machine that filters their blood for them. Their blood runs from their veins through a filter in what is called a dialyzer, which extracts the wastes and toxins that the kidneys would usually pull out. The blood returns through the patient’s arm like a reverse blood donation. Without dialysis, even patients in major hospitals can end up dying from minor complications.

Dr. Ball soon realized that he could do something about this lack of a basic health care necessity:

"I met up with another nephrologist, who had also noticed this issue. To start, we wrote letters to many of the large producers of hemodialysis units. Most of the companies were not interested in sponsoring a formal charity until we came across DaVita. I had dinner with the head of the company and he liked the idea and offered to provide used machinery. That was the start of Bridge of Life."

Bridge of Life seeks to provide dialysis treatment to many developing countries. Their focus thus far has been on hemodialysis as it has been easier to attain the machinery. Much like a car, dialysis machinery depreciates in value with “mileage.” Eventually the machine has no monetary value so companies are happy to hand it off even though it still functions adequately. This is how Bridge of Life acquires their units.

Q: What have been some of the biggest complications in setting up the charity?

A: Customs is probably the biggest [challenge]. Getting the equipment through customs and then avoiding exorbitant duty on the import has been the biggest issue. On top of that, the rules of customs changes with each country so just because you can get something through in India, doesn’t mean you will in Ghana. Second, there’s setting up the supply chain to the clinics we set up. In the US, a lot of materials like tubing and saline are cheap because there’s competition. But, in certain countries like Ghana, you may have only one importer of dialyzers and he is going to mark up the price as much as he wants because he knows you need it. Then there are training personnel to work with a piece of complicated machinery and showing them where we get the supplies. Those things are what we call logistics—and logistics and customs have been our biggest setbacks.

Despite these issues, the organization is still fighting to reduce inequality:

"Unless you start providing treatment, people die and it never gets better. You have to start somewhere. The hope is that we’ve stimulated people to start similar projects, attracted government attention and support. In the Philippines, the government even decided to start paying for dialysis because of the clinic we set up. Even though units failed, they stimulated a questioning of health care services in many places. India spends 1.6% of GDP on health care, compared to the average of 9% worldwide. Eventually people started questioning why this was."

For low-income patients, the leading cause of death is that they simply cannot afford treatment. This is a major issue with hemodialysis, which is why it is important to consider alternatives. Another treatment option is peritoneal dialysis. In this method, a catheter is inserted into the abdominal cavity and dialysate is added through the tube. This liquid has a low concentration of salts or dextrose and causes the capillaries in the digestive tract to spill their toxins into the cavity. The dialysate is removed several hours later and replaced. The benefit of this system is that it allows the patients to have a much higher quality of life than patients on hemodialysis as they have continuous treatment rather than spending weeks around a machine.

Q: So what about peritoneal dialysis? I know that it is generally considered cheaper and a number of studies show patients seem to prefer it.

A: It is cheaper and we have tried to integrate its use into some locations. The issue is that while the saline solution is cheap to produce, many countries just don’t have a factory to produce it. We’ve been trying to contact Baxter, the leading producer of dialysis solution, for help but as yet have not had a response.

Q: Where has your charity been most influential?

A: Africa. We’ve worked in India, the Philippines and much of South America and it’s completely different. In South America, they often had the educated personnel, but lacked machinery. In Ghana, Kenya and Tanzania, it’s been much more difficult. I was in Kenya and the nurses didn’t have the equivalent of a high school education. In Tanzania, there were 28 million people, but only 3 places large enough to be considered a hospital.

While many African countries have made improvements, the lack of a fully structured education system and the inability to import supplies has made it incredibly difficult to establish health care systems. Bridge of Life has 10 projects planned for this year—two in Ghana and one in Cameroon—that will hopefully achieve change. While these projects may likely not have a large immediate effect, the effort is still essential because it sets an example of what needs to be done. Even in failed locations, the attempt has been enough to change health care policies:

“Going in, you bring Western opinion, and they may not accept it but they do look at what you are doing and decide how they think about their own health care.”

Dr. Ball has spent much of the past 20 years devoted to spreading the word about this issue. However, at the end of the day, Bridge of Life is a relatively small organization facing a huge problem. While his charity work has faced huge obstacles and sometimes discouraging results, Dr. Ball reminds us that small changes can have lasting impacts, even if you do not see them right away.